Marie called with a question, “My baby is 4 weeks old, and my husband and I love her to death. However, she is a lot of work, and we do not want another little one quite yet. My husband and I are also hoping to resume our sex life, but can I be on birth control while breastfeeding?” 

MotherToBaby is here to help answer some of those questions!  Of course, before you decide, it is best to speak with your medical provider and get their advice.  Since everyone is different, some birth control methods might not be a good match for you.

Can breastfeeding be used as contraception?

There are many benefits to breastfeeding. Breastmilk has antibodies that are passed to the baby and help them build their immune system and protect against illnesses. Breastmilk is also a great source of nutrition. When a woman is breastfeeding, they might experience amenorrhea (when you do not have a monthly a menstrual period). Breastfeeding can be a temporary form of birth control if the person is exclusively breastfeeding (i.e., no formula), they have not had a menstrual period yet, and the baby is less than 6 months old. This method is sometimes called the “lactational amenorrhea method (LAM)”. LAM does not work for everybody and may not be reliable enough for all couples. Some people do not develop amenorrhea when breastfeeding, so another form of birth control would be recommended.

Are there other forms of birth control that I can use when breastfeeding?

Many contraceptive methods do not affect your breastfeeding.  However, options which contain estrogen might reduce your milk supply. Depending on what option you choose, your healthcare team may suggest that you wait up to 4-6 weeks after delivery so that your milk supply is well established, and your body has recovered from childbirth.

Another factor is how serious you are about preventing another pregnancy. Some options such as the IUD, hormonal implant, and Depo-Provera injection are 98-99% effective in preventing pregnancy (this means only 1 or 2 out of 100 women will get pregnant every year using those methods). The birth control pill is around 93% effective in preventing pregnancy (this means around 7 out of 100 women will get pregnant every year using birth control pills). The condom is around 85% effective, depending on how carefully it is used (this means around 15 out of 100 women will get pregnant every year using this method).

The American College of Obstetricians and Gynecologists (ACOG) has a web page that answers frequently asked questions about contraceptives including advantages and disadvantages of each type:  https://www.acog.org/womens-health/faqs/postpartum-birth-control

Hormonal Birth Control Options

There are many kinds of hormonal birth control options including pills taken orally (by mouth), injections, implants, and some IUDs. Some options contain forms of both estrogen and progesterone, and some just contain progesterone. In general, it is expected that only small amounts of the hormones would pass into your breastmilk, and these low levels are unlikely to result in any side effects in your baby. However, some of them can affect your milk supply.

Some estrogen-containing options include “combination birth control pills,” the skin patch, and the vaginal ring. A disadvantage of estrogen is that it can reduce or even stop milk supply. Healthcare providers usually recommend waiting to start estrogen-methods until at least 4 weeks after delivery to allow your milk supply to be well established.

Progesterone-only options include the progestin only pills (“mini pills”), the injection (ex. DepoProvera shot), the implant (ex. Nexplanon), the hormonal intrauterine device (IUD), and emergency contraception. Progesterone only options generally do not reduce your milk supply or affect milk quality. Some professional groups suggest waiting 4-6 weeks after giving birth before getting the Depo-Provera shot because the amount of hormone in your blood and milk from this injection are highest around the time it is given.

Non-Hormonal Birth Control Options

Non-hormonal birth control options include barrier methods like male and female condoms, spermicide, diaphragms, the cervical cap, the sponge, and the copper IUD.  None of these strategies impact milk supply. 

Fertility Awareness Methods/Lifestyle Options

Other birth control options that do not include hormones or barrier items are the calendar tracking option and abstinence. The calendar tracking option is when you track your menstrual cycle and avoid intercourse on the days you are most fertile (most likely to get pregnant). This method is not very reliable following childbirth because a menstrual cycle can be irregular during the first few months. Abstinence is the avoidance of vaginal intercourse and choosing to be intimate in other ways that cannot result in a pregnancy. Abstinence is 100% effective at preventing pregnancy.

Summary

In summary, what is the best birth control option during breastfeeding? Each person will be different, so it is important to talk with your healthcare provider about which option is best for you based on the timing, effectiveness, family planning decisions, and your other personal health factors.

Resources

2023. Postpartum Birth Control; Frequently Asked Questions. American College of Obstetrics and Gynecology. https://www.acog.org/womens-health/faqs/postpartum-birth-control

Berens P, Labbok M; Academy of Breastfeeding Medicine. ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015. Breastfeed Med. 2015 Jan-Feb;10(1):3-12. doi: 10.1089/bfm.2015.9999. PMID: 25551519.

2024. Contraception and Birth Control Methods. Centers for Disease Control and Prevention.  https://www.cdc.gov/contraception/about/index.html

2024. About Breastfeeding. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/php/about/index.html

Goulding Alison N., Wouk Kathryn, and Stuebe Alison M., Contraception and Breastfeeding at 4 Months Postpartum Among Women Intending to Breastfeed. Breastfeeding Medicine. January 2018, 13(1): 75-80.

Stanton TA, Blumenthal PD. Postpartum hormonal contraception in breastfeeding women. Curr Opin Obstet Gynecol. 2019 Dec;31(6):441-446. doi: 10.1097/GCO.0000000000000571. PMID: 31436540. 

By Lynn Martinez and Julia Robertson, CPM

During the more than 40 years MotherToBaby affiliates have been serving the public with education regarding exposures during pregnancy, many women have called who are very distressed, sometimes in tears, about finding out they were pregnant while taking a drug categorized as an X or D in the Food and Drug Administration (FDA) system. “I’ve been on birth control pills and I still got pregnant! Does this mean my baby will have birth defects? It’s a category X drug for goodness sake!” This kind of hysterical reaction was, unfortunately, a common call. It was not unusual to even hear that some of these women had contemplated terminations of otherwise wanted pregnancies. The FDA realized that these pregnancy categories were not as helpful as they intended and stopped using them in 2014, about ten years ago. Now they use the Pregnancy and Lactation Labeling Rule (PLLR) that has a narrative summary for medications, similar to what you will find here at MotherToBaby.

But first, a little background…

For decades the FDA had been aware of significant problems with the system used to categorize medications for use in pregnancy. In 1992, the Teratology Society (now known as the Society for Birth Defects Research and Prevention), a group of multidisciplinary scientists who study birth defects, expressed concerns and noted that the Category or ‘CAT’ system led to unnecessary terminations of wanted pregnancies1. The FDA Pregnancy Labeling Initiative recommended elimination of the CAT system, changing the label to include more descriptive risk statements and mandating that drug inserts be updated when human information is known.

Before the labeling rule changed, when a medication was approved for marketing in the U.S., it had to be labeled with one of five pregnancy CATs: A, B, C, D or X. A meant the drug was well-studied and posed no threat to a developing baby; B was a less-studied, but probably still low-risk drug; C was a drug that had not been studied and therefore the risk was unknown; a D-class drug, based on animal or human data, may have posed a risk; and the X classification meant the drug, based on animal or human data, causes birth defects or there was no benefit for its use during pregnancy. Its use was not recommended in pregnancy.

More than 90 percent of new medications were categorized as either CAT C, D or X, the vast majority being C. Drug manufacturers were legally required to update the category if harmful results were reported; however, no such requirement existed for updating the category when studies showed no problems in pregnancy. Most medications on the market in 2014 werelisted as CAT C, when in fact the majority of them should have been labeled as a CAT A or B. Manufacturers knew that no matter a woman’s history, all pregnancies carried a 3 percent risk of having a child with a major birth defect. Because of this, many manufacturers may have felt better protected from lawsuits if their drugs were listed as CAT C, D, or X. So, really, why would they move up medications in those categories up to A or B? They really didn’t have an incentive.

Moving forward and what it means to mom…

With the FDA rule change in 2014, a new set of requirements was put into place to better inform mom. It now requires the manufacturers to ‘upgrade’ a medication’s labeling when studies show the risk has changed. Also, manufacturers will have to explore various ways of discussing in detail the risks associated with the drug. One expert source that manufacturers could consult is a teratogen information service, like MotherToBaby. More information will help you make more informed choices about your health and pregnancy!

There will still be confusion…

As we see the new labels being implemented, there will still be many drugs on the market with the CAT system since it’ll take time to update all of them. MotherToBaby does not recommend the public or providers rely on the old CAT system for risk assessment. We welcome your questions about the system as well as questions about specific medications in pregnancy and breastfeeding for a complete, personalized risk assessment. Please call us toll-FREE at 866-626-6847.

Lynn Martinez is a retired Teratogen Information Specialist. Lynn has traveled around Utah educating doctors, nurse midwives, pharmacists and others over the past three decades.

Julia Robertson, CPM, now retired, works part-time overseeing quality control efforts for MotherToBaby. In her 25-year career as a teratogen information specialist, sheauthored several peer-reviewed publications focusing on maternal medication consumption and the effect on the developing fetus.

MotherToBaby is a service of the international Organization of Teratology Information Specialists (OTIS), a suggested resource by many agencies, including the Centers for Disease Control and Prevention (CDC). If you have questions about medications, alcohol, diseases, vaccines, or other exposures during pregnancy or breastfeeding, call MotherToBaby toll-FREE at 866-626-6847 or browse a library of fact sheets.

1. Friedman, J. Teratology 1993:48:506
2. For more information go to: http://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/labeling/ucm093307.htm

“I’m supposed to get dermal fillers tomorrow, is it still safe for me to get this procedure!?” Erin had booked this appointment with their dermatologist weeks ago, and while Erin was so excited today to learn that they were pregnant, they weren’t sure if the fillers were still a good idea. Hopeful for smoother skin and less noticeable wrinkles, they called us for guidance. Erin isn’t alone in having questions – MotherToBaby information specialists are often asked about getting cosmetic procedures during pregnancy or while breastfeeding.

Some cosmetic procedures require surgery; these are a type of plastic surgery. Examples include liposuction, breast augmentation, and rhinoplasty (nose). These types of cosmetic surgeries are best avoided while pregnant. But what about less invasive procedures? Let’s look at some commonly asked about treatments:

Botox

Botox is an injectable form of botulinum toxin. When used cosmetically, Botox is typically injected in the face or neck to help smooth out wrinkles or fine lines in the skin by temporarily paralyzing or relaxing the muscles. Botox is expected to stay in the area where it is administered and not enter the bloodstream. Because of this, it is unlikely to enter breast milk or to cross the placenta where it could reach a developing baby. However, it is important to note that Botox hasn’t been studied specifically for use during pregnancy or breastfeeding. There is also a risk for infection at the injection site, and the possibility that the toxin could spread beyond the area where it was administered. Read more about Botox here: https://mothertobaby.org/baby-blog/botox-baby-what-we-know-about-the-risks-during-pregnancy-breastfeeding/

Semi-Permanent Makeup & Microblading

Semi-permanent makeup is achieved by tattooing areas of the face to highlight natural features and typically lasts for a few years before fading. This might include eye liner, lips, or eyebrows. Microblading is another form of tattooing used on the eyebrows. When it comes to the ink used in semi-permanent makeup, it isn’t clear how much of the pigment in the ink is able to enter the blood stream, cross the placenta, or how much is able to reach the baby. For folks who are breastfeeding, it also isn’t clear how much of the pigment might pass into breast milk. This makes it difficult to know if the pigment itself might cause a risk. We do know that with any tattoo, there is a possibility of infection if the equipment is not sterilized properly. There can be a risk for Hepatitis B, Hepatitis C, HIV, and other infections like staph. There is also a possibility of infection during the healing process. If you do choose to get semi-permanent makeup while pregnant or breastfeeding, be sure to go somewhere that is practicing good hygiene. Also be sure to contact your healthcare provider if the tattooed area seems like it isn’t healing correctly.

Teeth Whitening

Many people are also interested in brightening up their pearly whites. Some common teeth whitening products include whitening strips, whitening toothpastes, at home Blue (LED) Light Therapy, and professional whitening procedures administered by a dental hygienist or dentist. For the most part, these products are not expected to increase risks to a pregnancy or a breastfeeding baby. For more details about specific ingredients in teeth whitening products see: https://mothertobaby.org/baby-blog/whitening-teeth-during-pregnancy-or-breastfeeding-lets-bite-into-the-subject/

Chemical Peels

There are a few different types of cosmetic chemical peels that are used to address uneven skin tones, wrinkles, acne scarring, or sun damage by applying a product on the skin (topically) that then removes part of the upper layers of the skin. This usually involves a type of acid – it might be a combination of hyaluronic acid, glycolic acid, trichloroacetic acid, salicylic acid, or lactic acid and other ingredients. Light chemical peels involve the outer layer of skin (epidermis). Deep chemical peels can penetrate a bit further into the layers of your skin. Because the chemicals in each peel can vary, it can be a good idea to ask ahead of time for an ingredient list. A MotherToBaby specialist can talk with you about the active ingredients in the specific chemical peel you are considering. Read more about your skin & skin care here: https://mothertobaby.org/baby-blog/whats-the-skinny-on-skin-care

Lip Fillers & Dermal Fillers

Lip and dermal (or face) fillers are injected substances that are used to fill in lines and wrinkles or add volume to areas in the face or lips. There are currently four types of fillers that are approved by the Federal Drug Administration (FDA). Hyaluronic acid fillers are the most common. Hyaluronic acid, along with Calcium hydroxylapatite and Polylactic acid fillers are considered temporary – these will eventually be broken down and absorbed by the body. Polymethylmethacrylate is not absorbed by the body – this filler is made up of small round plastic beads suspended in collagen. So what do we know about the use of fillers during pregnancy or breastfeeding? The answer is not much. There is limited research on these substances when administered during pregnancy or while breastfeeding, so it may be best to pause any injections until a later date. There is also a potential risk for infection at the injection site. The FDA advises anyone interested in fillers to get them from a licensed healthcare provider and to discuss the risks and benefits with them before the procedure.           

So, what did Erin do about their appointment for dermal fillers?

When it comes to cosmetic procedures while pregnant or breastfeeding, it is important to consider what is known about a procedure and weigh any potential risks. In Erin’s case, they decided it would be best to wait to reschedule their next dermal filler appointment until after their child was born. They ended our call by telling me, “I think it will give me more peace of mind to cancel my appointment and wait until after my pregnancy now that I know there isn’t much research. I’ll talk to my dermatologist about other skin care options in the meantime.” 

Do you have a question about a cosmetic procedure during pregnancy or breastfeeding?

Speak with a MotherToBaby specialist via phone, text, chat, or email.

Teratogen Exposure Guidance for Pharmacists with Pregnant and Lactating Patients

Many people need to take prescription or over-the-counter medication when pregnant or breastfeeding. However, the dearth of adequate pregnancy or lactation safety data can make risk assessment complex and laborious for a busy pharmacist. We understand the challenges that you face when counseling pregnant and lactating patients on medication exposure risks, especially if there are multiple prescriptions and complex medical illnesses to consider. This is where we can help.

We specialize in evaluating teratogenic risks associated with maternal medication use in pregnancy and lactation. We provide no-cost, evidence-based information in a patient-friendly manner that will help you weigh the risks and benefits of a medication for both parent and baby, allowing you to educate your patient about how best to maximize disease treatment while minimizing maternal and fetal/infant risk.

We are also dedicated to furthering the information and understanding of medication safety in pregnancy through our observational MotherToBaby Pregnancy Studies. We are proud to lead more than half of all Food and Drug Administration (FDA)-mandated pregnancy registries conducted in the U.S. MotherToBaby Pregnancy Studies are rigorously designed cohort studies that aim to provide critically needed product safety information – and your patient referrals make all the difference. With your referral, you are helping us generate data that will lead to improved product safety information in pregnancy, thereby providing you and your patients with the evidence you need to make more informed treatment decisions.

Most pharmacists will encounter questions regarding the safety of medication use during pregnancy and breastfeeding either from patients, family, or friends. Many may feel that they lack the knowledge to answer these questions confidently.

— Burkey et al., 2013

Explore how we can help you and your pregnant and breastfeeding patients by providing no-cost exposure risk assessments, patient education materials, observational studies to monitor pregnancy outcomes, and more.

By Patricia Markland Cole, MPH, MotherToBaby Massachusetts

**This information was current as of the time the blog was published. However, information is constantly changing. Please visit Zika Central for the latest information.**

Zika, Zika, Zika……everywhere you turn someone is talking about Zika and it’s not hard to understand why. Last fall in Brazil, the cases began coming in with unusual frequency. Health care providers noticed an increase in babies born with small heads and small brains, a birth defect called microcephaly. And the questions began pouring in as to why this could be happening? Providers noticed these women lived in or had visited areas affected by the Zika Virus; in fact, out of the first 35 case reports of microcephaly the majority of the moms reported a rash-like illness and some tested positive for Zika.

When Zika hit the news, it was understandably scary for pregnant woman. One of our most vulnerable populations – our babies– are at risk from something we can’t even see with our natural eyes: a virus carried by a mosquito. While we still have much to learn about Zika and pregnancy (including whether it is actually associated with microcephaly), the possibility that there is a risk takes away from the joy and celebration that pregnant woman normally feel and has replaced that with fear and trepidation. As a counselor with MotherToBaby, I know. I’ve heard the fear in the voices of women calling me; even through emails and text messages, the concern has been palpable. So let’s put it all into perspective.

Focusing Away From Fear: If You’re Planning A Pregnancy…
While there is so much focus on the fears of pregnant woman, there are very real concerns that the woman or couple planning for pregnancy experience as well. Just the other day, I had a conversation with a woman who contacted our service hoping to get some answers. “I am planning to go through IVF and scheduled a trip to Mexico well in advance of the news about Zika. My plan was to go to Mexico and start going thru IVF when I came back. Do I have to cancel my trip or if I go do I have to delay my plans for pregnancy, and, if so, for how long. It is hard to think of delaying pregnancy but at the same time we were so looking forward to this trip and planned it long ago!” I could hear the struggle.

We’re still learning about Zika, but for couples planning a pregnancy the current recommendation is that you talk with your physician about how your plans could be affected by travel to a Zika–affected area. Zika usually remains in the blood for a week after infection and there is currently no evidence to suggest an increased risk of birth defects if a woman becomes pregnant after the infection has passed.

If You’re Pregnant…
Zika can be spread from a pregnant woman to her baby. The link between Zika and microcephaly is still being investigated, but to be safe the US Centers for Disease Control and Prevention (CDC) currently recommends that pregnant women consider postponing travel to any area where Zika virus is spreading. If travel to an affected region cannot be avoided, you should talk to your healthcare provider before leaving, and while traveling take careful steps to prevent mosquito bites (see below). If you’ve recently completed your travel, you should still talk to your healthcare provider, even if you don’t feel sick.

Zika Can Be Transmitted Through Sexual Contact.
For men, Zika can remain in semen for a longer period of time so it is important to speak with your healthcare provider regarding risks. If a man has traveled to a Zika-affected region and has a pregnant partner, it has been recommended that he use condoms during sex (vaginal, anal, and oral) for the remainder of the pregnancy. For couples planning a pregnancy, it has been recommended that men use condoms for 28 days after traveling to Zika infected areas. For more details, see our fact sheet, Zika and Pregnancy https://mothertobaby.org/fact-sheets/zika-virus-pregnancy/.

Travel and Mosquito Bite Prevention
It is important to check travel advisories for the area you plan to visit because the status of areas can change before your trip quite rapidly. For example, prior to traveling to Florida a physician called me about the safety for his wife to use DEET during pregnancy. At the time there were no advisories for the area but shortly thereafter, the Governor of Florida issued a state of emergency for some counties that had reported cases of Zika infection that were linked to people who had traveled to Zika-affected areas. Therefore it is important to always check the CDC website for travel information (http://wwwnc.cdc.gov/travel/page/zika-travel-information) and to take the necessary precautions to protect yourself from mosquito bites. These include:

1. Wear long sleeve shirts and pants;
2. Use mosquito repellent with an EPA registered number as this means that the repellant has been proven safe and effective like DEET and picaridin; both of these agents are considered compatible for pregnancy. Make sure to read the label and follow the instructions, as you may need to reapply insect repellant every few hours. If you are using sunscreen, apply that first and then add the insect repellant. You can get more info on insect repellant use during pregnancy from our new Fact Sheet at https://mothertobaby.org/fact-sheets/insect-repellents/;
3. Stay in air-conditioned areas;
4. Stay in areas with screened doors, and sleep with mosquito netting.

Mosquito-transmitted Viruses are Nothing New
Zika is just the latest punch from these biting bullies. In fact, taking steps to avoid mosquito bites is something we should all be doing, as there are quite a few diseases they can pass on to humans. Some are more common in tropical areas but can also be found here in the United States like Dengue and West Nile Virus. Both conditions are associated with uncomfortable symptoms, dengue can pose complications for pregnancy and the effects of West Nile during pregnancy are not that well known – so protection at all times is key. Thankfully, neither are as frequent in the United States or Canada as in some other parts of the world due to the use of insect repellants and other protective measures we have. For more info, check out our West Nile Virus Fact Sheet at https://mothertobaby.org/fact-sheets/west-nile-virus-infection-pregnancy/

Remember: if you are not pregnant, Zika virus overall does not cause serious effects. It is only when a woman gets Zika during pregnancy that experts suspect (but have not yet proven) that it may increase the risk of birth defects so there is still more to learn.
It’s been said that the only thing that remains constant is change. Whether it’s Zika or the next mosquito-transmitted outbreak, fight the bite and navigate those changes. MotherToBaby is here to help.

Patricia Cole, MPH, is the Program Coordinator for MotherToBaby Massachusetts. She obtained her Bachelor’s degree in Biology from Simmons College in Boston and her MPH in Maternal and Child Health from Boston University School of Public Health. She has been the serving the families of New England as a teratogen counselor since 2001 and provides oversight for the day-to-day functions and outreach of the program. She has also provides education to graduate students and other professionals.

MotherToBaby is a service of the international Organization of Teratology Information Specialists (OTIS), a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about viruses, alcohol, medications, vaccines, diseases, or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or try out MotherToBaby’s new text counseling service by texting questions to (855) 999-3525. You can also visit MotherToBaby.org to browse a library of fact sheets, email an expert or chat live. MotherToBaby recently released an evidence-based Zika virus fact sheet for concerned pregnant and breastfeeding women. It can be found here: https://mothertobaby.org/fact-sheets/zika-virus-pregnancy/